Abortion, Medical Issues

Scholars have shown that for every society for which some recorded history exists, there is evidence of abortion. Indeed after an exhaustive review of materials from three hundred fifty ancient and pre-industrial societies, the anthropologist George Devereux (1954) concluded, "There is every indication that abortion is an absolutely universal phenomenon, and that it is impossible even to construct an imaginary social system in which no women would ever feel at least compelled to abort" (p. 98). One of the earliest known medical texts, attributed to the Chinese Emperor Shen Nung (2737–2696 bce), refers to mercury as a substance that will "cause abortion." The Ebers Papyrus of Egypt (1550–1500 bce) contains several prescriptions for abortion, including one that combined acacia leaves and the plant colocynth, both of which have been shown in laboratory tests to have certain anti-fertility properties.

In both classical Greece and Rome, abortion was apparently widely practiced and highly visible. Most abortions were attempted through herbal preparations, but archaeological evidence indicates that in the Greco-Roman era, there were several types of vaginal specula, as well as an apparatus designed to irrigate the intrauterine cavity. Specific instruction in abortion through instrumentation is found in the writings of the tenth century Persian physician Al-Rasi (Joffe 1999).

MODERN METHODS OF ABORTION

Despite this striking record of early understandings of abortion techniques, this knowledge appeared to be willfully forgotten as abortion became increasingly controversial. For the next several centuries the medical profession, for the most part, ignored abortion, with the procedure being offered by some physicians only to a select few patients, while other women attempted self-abortions or received them from the hands of nonphysicians with varying skill levels. It was not until the mid-nineteenth century that the medical profession began to rediscover and refine what had been known to practitioners centuries earlier (Joffe 1999).

Dilation and Curettage (D&C) and Vacuum Aspiration

In 1842, the modern curette (from the French verb, curer, "to cleanse") was adapted for use in the uterus, and dilators (for opening the cervix) were developed by the German physician Alfred Hegar in the 1870s. Dilatation and curettage, or, as it is commonly known, "D&C," became the leading form of abortion as practiced by physicians.

The D&C method of performing first trimester abortions eventually was replaced in most of the developed world by the vacuum suction machine, also known as the vacuum aspiration method. This method is greatly preferred by practitioners because it replaces the "sharp curettage" of the D&C and causes less blood loss and injury. In the developing world, however, because of a lack of training opportunities and equipment, vacuum aspiration has been slower to replace the D&C method.

Early Abortion Methods: Medication Abortion and Manual Vacuum Aspiration

Several important advances in abortion technology took place toward the end of the twentieth century, developments which both allow abortions to be delivered earlier in pregnancy than conventional vacuum aspiration, and in the case of women in the developing world, more accessibly. The first was the discovery of mifepristone (formerly known as "RU-486" or the "abortion pill"), by a team of French scientists led by Etienne Baulieu. This pill, when taken with another medication, misoprostol, is highly effective in terminating abortions for up to eight or nine weeks. Because administration of this form of abortion does not require specialized surgical training, it can be dispensed by a wider variety of providers, and in a greater range of medical settings than aspiration abortion. Since its introduction in France in 1988, tens of millions of women worldwide have had mifepristone abortions.

Another form of medication abortion is use of the drug methotrexate in combination with misoprostol. Methotrexate is a drug that is primarily used in cancer treatment and for several other purposes. Although most abortion providers prefer mifepristone because of its faster action and higher success rate, methotrexate is also effective for terminating ectopic pregnancies, while mifepristone is not.

The use of misoprostol (the second drug in the mifeptristone regime) alone is an additional form of medication abortion that is seeing increasing usage, particularly in the developing world where abortion remains illegal. Known primarily by its most common trade name, Cytotec, this is an ulcer medication that can be bought over the counter in many areas; in women who are pregnant, the drug causes the uterus to contract and begin a miscarriage. Gynuity Health Projects, a non-governmental organization specializing in reproductive health, has taken the lead in disseminating guidelines on the most effective use of misoprostol alone (Gynuity Health Projects 2007).

Finally, the late 1990s saw the reintroduction into abortion providing circles of the MVA, or Manual Vacuum Aspirator. This handheld device can be used very early in pregnancy, as soon as a pregnancy is confirmed (while conventional vacuum aspiration is typically not performed until about six or seven weeks after a missed period). Another advantage, pertinent to the developing world, is that the MVA is not dependent on a source of electricity.

Later Abortions

The major form of second trimester abortion as practiced in the United States and parts of Europe is a procedure called dilatation and evacuation (D&E). This procedure is often a two-day process. Laminaria, a seaweed preparation, or a similar manufactured preparation, is inserted into the woman's cervix to help it dilate. A substance, digoxin, is used by many physicians to cause fetal demise, and then the fetus is surgically removed. A rarely used variation of the D&E is "intact dilatation and extraction" in which the fetus is removed intact, after partial (passage through the birth canal) vaginal delivery. Intact D&Es (sensationalized by abortion opponents in the United States as "partial birth abortions") accounts for less than one percent of all abortions performed in the United States (Finer and Henshaw 2003) and are typically performed to preserve the pregnant woman's health.

RISKS OF ABORTION

When performed by trained providers, abortion is one of the safest of all medical procedures. After the legalization of abortion in the United States in 1973, the risk of death associated with abortion fell to less than 0.6 per 100,000 procedures, leading the Council of Scientific Affairs of the American Medical Association to conclude that the risk of death from abortion was less than one tenth as large as the risk from dying in childbirth (Council on Scientific Affairs, AMA 1992).

Of the approximately seven hundred thousand mifepristone abortions that have taken place in the United States since 2000, there have been only four deaths associated with a rare C. Sordellii infection, and one from an additional infection, leading to an approximate mortality rate of 1/140,000 total infection deaths. The C. Sordellii infections continue to puzzle researchers and have been associated with other reproductive events as well, including births and miscarriages, and it is unclear as of this writing whether mifepristone or misoprostal had any role in causing these deaths (Winikoff 2006).

For those women in the developing world, however, who do not have access to safe abortion, the situation is very different. The World Health Organization estimates that some sixty-eight thousand women die each year from unsafe abortions and many thousands more are severely injured (Ahman and Shah 2004).

BIBLIOGRAPHY

Ahman, Elisabeth, and Iqbal Shah. 2004. Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion in 2000. 4th edition. Geneva: World Health Organization.

Council on Scientific Affairs, American Medical Association, 1992. "Induced Termination of Pregnancy Before and After Roe v Wade." Journal of the American Medical Association, 268 (22): 3231-3239.

Devereux, George. 1954. "A Typological Study of Abortion in 350 Primitive, Ancient and Pre-industrial Societies." In Therapeutic Abortion: Medical, Psychiatric, Anthropological, and Religious Considerations, ed. H. Rosen. New York: Julian Press.

Finer, L., and S. Henshaw. 2003. "Abortion Incidence in the United States in 2000." Perspectives on Sexual and Reproductive Health 35(1): 6-15.

Gynuity Health Projects. 2007. Instructions for Use of Misoprostal in Women's Health. Available from http://www.gynuity.org.

Joffe, C. 1999. "Abortion in Historical Perspective." In A Clinician's Guide to Medical and Surgical Abortion, ed. M. Paul, E. Lichtenberg, L. Borgatta, D. Grimes, and P. Stubblefield. New York: Churchill Livingstone.

Winikoff, B. 2006. "Clostridium Sordellii Infection in Medical Abortion." Clinical Infectious Diseases 43: 1447-1448.

                                                  Carole Joffe